SURVEY BRIEF SEPTEMBER 2019 What Do Several polls have indicated that health care will be a top issue for Americans in their choice of nominee for the 2020 presidential election.1 While the Affordable Care Act Americans (ACA) has dramatically cut the number of Americans without health insurance, reduced consumers’ overall out-of-pocket spending, and ensured that people with preexisting health conditions can get the coverage they need, significant problems remain: about 30 Think About Their million people remain uninsured, an estimated 44 million are underinsured, and health care costs are growing faster than median income in most states.2 Health Coverage Several of the Democratic candidates have proposed health reform plans aimed at addressing these problems. Their proposals range from building on the ACA’s coverage Ahead of the expansions, such as providing more generous subsidies for those purchasing coverage, to creating a public plan option or reorganizing the health system to make a public plan like 2020 Election? Medicare the nation’s primary source of coverage. The Commonwealth Fund’s new Health Insurance in America Survey provides the latest information on the state of health insurance coverage for working-age adults, their Findings from the Commonwealth coverage experiences and views, and their views of current health policy proposals. To conduct the survey, the survey research firm SSRS interviewed a nationally representative Fund Health Insurance in America sample of 4,914 adults ages 19 to 64 from March 19 through June 9, 2019. Seventy percent Survey, March–June 2019 of respondents completed the questionnaire by landline or cell phone, while 30 percent completed it online after being contacted by mail. (This approach represents a significant change from the previous sampling methodology used for the survey and affected trends in responses to certain questions. See “How We Conducted This Study” for more detail.) SURVEY HIGHLIGHTS Sara R. Collins 13.8 percent of U.S. working-age adults are uninsured, down from 19.9 percent just prior Vice President to the ACA’s coverage expansions — statistically the same as in 2018. The Commonwealth Fund Just over a quarter (27%) of adults favor eliminating all private health insurance and Munira Z. Gunja making public insurance like Medicare the only coverage option. But 40 percent said Senior Researcher The Commonwealth Fund they do not know enough to form an opinion. What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 2 While a larger percentage of Democrats (43%) HOW WE CONDUCTED THIS STUDY favored replacing all The Commonwealth Fund Health Insurance in America Survey, sample for questions on consumers’ experience using the private insurance with a March–June 2019 was conducted by SSRS from March 19 to June marketplace, getting coverage under the ACA, and using their 9, 2019. The survey consisted of interviews conducted via web new coverage. public plan compared to and telephone in English or Spanish among a random, nationally To counteract known biases inherent in ABS samples and to yield Republicans (12%) and representative sample of 4,914 adults, ages 19 to 64, living in a more representative group of respondents, the ABS sample independents (27%), 41 the United States. Overall, 1,453 interviews were completed via was disproportionately stratified to target addresses in areas the online survey and 3,461 were completed via phone (either with lower mean household incomes, as well as addresses in percent said they did not landline or mobile). areas with high Hispanic incidence. The stratification was done know enough to say. This survey is the eighth in a series of Commonwealth Fund at the Census Block Group level based on data available from surveys to track the implementation and impact of the Affordable the Census Planning Database. The ABS also included a separate More than two-thirds Care Act (ACA). Prior waves were part of the Commonwealth listed low-income stratum. (68%) of adults in Fund Affordable Care Act Tracking Survey. To see how the survey Data were weighted to ensure the final outcome was states that have not yet was conducted in prior waves, see here. representative of the adult population ages 19 to 64. The data are expanded Medicaid favor Unlike prior years, an address-based sample (ABS) was included weighted to correct for oversampling uninsured, direct purchase in Wave 8. This change in sampling method and mode of and Medicaid respondents, the stratified sample design, the expanding eligibility for response likely affected the trend on some measures between overlapping landline and cellular phone sample frames for the program. Majorities 2018 and 2019. However, the ABS sample was designed to mirror the Omnibus prescreened completes, and disproportionate of Democrats (91%) and as closely as possible the RDD sampling approach used for the nonresponse that might bias results. In this wave’s sample telephone sample. design, the weights also corrected for oversampling respondents independents (74%) As in all waves of the survey, the March–June 2019 sample was with a prepaid cell phone. The telephone and ABS samples favor doing so, while were weighted separately to be representative of the target designed to increase the likelihood of surveying respondents Republicans are split, who had gained coverage under the ACA. Interviews in Wave 8 population on the following parameters: age, gender, race/ ethnicity, education, geographic division, population density, with 42 percent in favor were obtained through three sources: 1) a stratified RDD sample, using the same methodology as in Waves 1–7; 2) a stratified and telephone use. All parameters were extracted from the U.S. and 48 percent opposed. Census Bureau’s 2017 American Community Survey data, with address-based sample of the population; and 3) households reached through the SSRS Omnibus where interviews were the exception of the telephone use benchmarks which was Large majorities of previously completed with respondents ages 19 to 64 who were extracted from the latest available estimates from the Centers insured adults are uninsured, had individual coverage, had a marketplace plan, or for Disease Control and Prevention’s National Health Interview satisfied with their had public insurance. SSRS oversampled adults with incomes Survey (NHIS). current coverage, below 250 percent of poverty to further increase the likelihood of The resulting weighted sample is representative of the surveying respondents eligible for the coverage options as well as approximately 190 million U.S. adults ages 19 to 64. Data for with those enrolled in allow separate analyses of responses of low-income households. income, and subsequently for federal poverty level were imputed Medicaid and employer A comparable, stratified design was used for the address-based for cases with missing data utilizing a standard general linear plans the most satisfied. sample. The uninsured and those with Medicaid and marketplace model procedure. The survey has an overall margin of sampling insurance were oversampled more directly using numbers error of +/– 1.9 percentage points at the 95 percent confidence for individuals (cell sample) and households (landline sample) level. The overall response rate, including the prescreened prescreened in the SSRS Omnibus in order to insure an adequate sample, was 7.6 percent. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 3 Adult uninsured rate remains significantly below pre-ACA levels, but coverage Adult uninsured rate remains significantly below pre-ACA levels, but coverage gains have stalled. stalled. gains have Percent of adults ages 19–64 who were uninsured As of March–June 2019, 13.8 percent of adults ages 19 to 64 were uninsured. This 25 estimate is not statistically different from uninsured rates in any year following 19.9 20 the 2014 rollout of the ACA’s major expansions of coverage.3 It is also consistent 14.8 15.5 with results of other surveys 15 13.3 14.0 13.8 showing the uninsured rate 12.7 holding steady or slightly increasing (see Uninsured 10 Rate for U.S. Adults Compared to Other National Surveys Since 2013). Adults with low incomes, young 5 adults, and Hispanics or Latinos — groups that made the greatest gains in coverage 0 in the years following the July–Sept. Apr.–June Mar.–May Feb.–Apr. Mar.–June Feb.–Mar. Mar.–June coverage expansions — 2013 2014 2015 2016 2017 2018 2019 continue to have among the highest uninsured rates (Table 1). Data: Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, Apr.–June 2014, Mar.–May 2015, Feb.–Apr. 2016, Mar.–June 2017, Feb.–Mar. 2018; and Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). Data: Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, Apr.–June 2014, Mar.–May 2015, Feb.–Apr. 2016, Mar.–June 2017, Feb.–Mar. 2018; and Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 4 Among uninsured adults who knew the mandate penalty was repealed, one-quarter Among uninsured adults who knew the mandate penalty was repealed, one-quarter chose chose not to get coverage because of the repeal. not to get coverage because of the repeal. Starting in 2019, people in most states Did you choose not to get health This year is the first in will no longer have to pay a penalty on insurance for 2019 because in most which Americans no longer their federal tax return if they don’t states people will no longer have to pay face a tax penalty for not have health insurance. Are you aware a penalty on their federal tax return if having health insurance: of this change? they don’t have health insurance? Congress repealed the penalty, effective 2019. At Percent of adults ages 19–64 who responded Percent of uninsured adults ages 19–64 who were the time of the survey, three they were aware of penalty change* aware of the penalty change and chose not to get states — Massachusetts health insurance because of the penalty change New Jersey, and Vermont — as well as the District of 54 55 Columbia had passed 48 legislation establishing an individual mandate.4 Among survey respondents 27 living outside these states, 24 22 54 percent were aware of the change in federal law, including 55 percent of insured adults and 48 percent of uninsured adults. All Insured adults Uninsured adults All <250% FPL 250%+ FPL Among uninsured adults who were aware the penalty * Does not include adults who live in one of the three states, or the District of Columbia, that has an individual mandate penalty: Massachusetts, New Jersey, or Vermont. Note: FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. was no longer in effect, Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. 24 percent said they chose not to get health insurance Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). this year because of the * Does not include adults who live in one of the three states, or the District of Columbia, that has an individual mandate penalty: Massachusetts, New Jersey, or Vermont. change. This translates Note: FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. into about 11 percent of all Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. uninsured adults.5 commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 5 Affordability is the top reason why Americans who shopped for marketplace Affordability didn’t enroll in a plan. coverage is the top reason why Americans who shopped for marketplace coverage didn’t enroll in a plan. About 18 percent of U.S. Coverage of adults by March–June who visited Can you tell me the MAIN reason you adults shopped for health the marketplace in 2019 did not obtain a private health insurance insurance in the ACA plan or Medicaid coverage when you marketplaces in 2019. Of this visited the marketplace? group, by March–June, 26 percent reported having a Percent of adults ages 19–64 who visited the Percent of adults ages 19–64 who visited the marketplace plan. Another marketplace* marketplace but did not select a marketplace 18 percent had enrolled in plan or Medicaid coverage Medicaid, and 26 percent had employer coverage; 18 You could not percent were uninsured.6 find a plan you 26 26 could afford We asked people who visited 26% the marketplaces but didn’t You obtained health insurance end up enrolling in a plan 18 18 through a or in Medicaid why they 51% different source hadn’t. Half (51%) said the 12 4% You decided you didn’t need main reason was that they health insurance couldn’t find an affordable 18% plan, while one-quarter Some other Marketplace Medicaid Employer Uninsured Other** reason^ (26%) had gotten insurance through another source. Four percent decided that * 18% of adults visited the marketplace or had someone else go to the marketplace to shop for the respondent’s/family’s health insurance. ** “Other” includes adults who purchased a health insurance plan directly through an insurance company, adults covered by Medicare, or any other type of insurance. ^ Respondents who reported “some other reason” cited missed deadlines and citizenship status, among other reasons. they didn’t need health Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. insurance. About one in five * 18% of adults visited the marketplace or had someone else go to the marketplace to shop for the respondent’s/family’s health insurance. cited other reasons, such ** “Other” includes adults who purchased aSara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the Source: health insurance plan directly through an insurance company, adults covered by Medicare, or any other type of insurance. Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). as their citizenship status ^ Respondents who reported “some other reason” cited missed deadlines and citizenship status, among other reasons. or missing the enrollment Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. deadline. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 6 Replacing private insurance with public insurance like Medicare does not have Replacing private insurancemany need morelike Medicare does not have strong strong support, but with public insurance information. support, but many need more information. Would you favor or oppose eliminating all private health insurance and making public insurance Several Democratic presidential candidates like Medicare the ONLY health insurance option for everyone, or do you not know enough about and members of Congress have proposed this to say? ways to increase insurance coverage and lower premiums and other health care costs.7 These Percent of adults ages 19–64 range from raising the subsidies available for marketplace plans and covering uninsured Strongly/somewhat favor Strongly/somewhat oppose Don't know enough to say people in states that haven’t expanded Medicaid, to replacing most insurance with a public program like Medicare. All 27 32 40 When survey participants were asked about their views on a “Medicare for all”–type approach8 — specifically, one in which a public Republican 12 60 27 program like Medicare becomes the only health insurance option for everyone — just over a quarter (27%) of adults said they were Democrat 43 15 41 in favor of it. But two in five adults (40%) said they did not know enough to say whether they favored or opposed such an approach. Independent 27 34 38 While Democrats were the most strongly in favor of replacing all private insurance with a public plan, 41 percent indicated they Note: Segments may not sum to 100% because of rounding. needed more information to offer an opinion. Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. Republicans were among the most strongly opposed to the proposal, with only 27 percent Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). saying they didn’t know enough to say (Table 2). However, Republicans with lower incomes were much less likely to oppose Note: Segments may not sum to 100% because of rounding. the approach than were higher-income Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. Republicans (41% v. 71%) (data not shown). commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 7 There is strong public support for expanding Medicaid in the states that haven’t yet done so. There is strong public support for expanding Medicaid in the states that haven’t yet done so. Under the health reform law, many Americans have gotten covered by Medicaid. States can Seventeen states have not yet expanded choose whether to expand Medicaid to cover more of their residents. Do you generally favor eligibility for Medicaid, including two or oppose expanding Medicaid? of the most populous states, Florida and Texas.9 An estimated 4.5 million people Percent of adults ages 19–64 who live in a state that did not expand Medicaid and strongly/somewhat who would otherwise be eligible for favor expansion* Medicaid are uninsured in those states.10 All <250% FPL We asked adults in states that have 250%+ FPL not expanded Medicaid whether they generally favored or opposed expanding eligibility. More than two-thirds (68%) 91 90 91 of respondents in those states favored 81 expansion. Majorities of Democrats (91%) 77 74 68 66 and independents (74%) were in favor. 60 57 Republicans were split, with 42 percent in favor and 48 percent opposed (Table 3). 42 Support for Medicaid expansion in these 32 states was stronger among Republicans and independents with lower incomes. A l < 2 0 F P 5 % L 2 5 %F P 0 + L A l < 2 0 F P 5 % L 2 5 %F P 0 + L A l < 2 0 F P 5 % L 2 5 %F P 0 + L A l < 2 0 F P 5 % L 2 5 %F P 0 + L More than half (57%) of Republicans with All Republican Democrat Independent incomes under 250 percent of the federal poverty level ($30,350 for an individual * The following states have not expanded their Medicaid programs: AL, FL, GA, ID, KS, MS, MO, NC, NE, OK, SC, SD, TN, TX, UT, WI, and WY. Ballot initiatives to expand were approved in three states — ID, NE, and UT — but the states have not yet expanded. and $62,750 for a family of four) favored Note: FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. Medicaid expansion, compared to one- third (32%) of Republicans with incomes Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the that level. Among independents, above Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). 81 percent of those with lower incomes were in favor of expansion, compared to * The following states have not expanded their Medicaid programs: AL, FL, GA, ID, KS, MS, MO, NC, NE, OK, SC, SD, TN, TX, UT, WI, and WY. Ballot initiatives to expand were approved in three states — ID, NE, and UT — but the states have not yet expanded. 66 percent of those with higher incomes. Note: FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. There was no difference in support by Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. income among Democrats. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 8 Most adults were satisfied with their current health coverage, with those enrolled in Most adults were satisfied with their current health coverage, with those enrolled in Medicaid and employer plans the most satisfied. Medicaid and employer plans the most satisfied. One of the key challenges faced by Overall, how satisfied are you with your health insurance? policymakers seeking to reform the health care system is that Americans who have health insurance are Percent of insured adults ages 19–64 Very satisfied generally satisfied with it. Somewhat satisfied Large majorities of those we surveyed were either somewhat or very 90 satisfied with their health insurance. 85 86 Satisfaction was particularly high 74 among people with Medicaid and employer coverage. An estimated 228 48 48 55 million people are enrolled in either 35 insurance type.11 Satisfaction was lower among those with coverage purchased on the individual insurance market 37 38 34 39 and marketplaces, an estimated 14 million people. However, there were significant differences by income. All Employer Medicaid Individual* People with incomes under 250 percent of poverty, who pay less for * Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. Note: Segments may not sum to total because of rounding. their premiums and face lower cost- Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. sharing, reported higher satisfaction with their coverage than those with Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). higher incomes (84% vs. 65%) (Table 4). People with incomes at or above this * Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. level pay more, or all, of their premium Note: Segments may not sum to total because of rounding. and do not receive cost-sharing Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. subsidies. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 9 Nearly two in five adults lacked confidence in affording health care if they became Nearly two in five adults lacked confidence in affording health care if they became very sick. very sick. Despite people’s satisfaction How confident are you that if you become seriously ill you will be able to afford with their current source the care you need? of coverage, many lacked confidence about being able to afford their health care if they Percent of adults ages 19–64 who were not too or not at all confident became seriously ill. Thirty- eight percent of all adults were Not at all confident 72 either not too confident or not Not too confident at all confident they would be able to afford their care. This included 29 percent of those with employer coverage, 39 percent of those with Medicaid, 39 41 53 38 and 41 percent with individual- market plans. Uninsured adults 29 expressed the greatest concern 21 21 20 about the future: 72 percent 12 were not too or not at all confident they would be able to 18 17 18 20 19 afford their care if they became seriously ill. All Employer Medicaid Individual* Uninsured Confidence was lower among people with lower income (Table 5). Nearly half (46%) of * Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. adults with incomes under 250 percent of poverty were not too Source: Sara R. Collins and Munira Z. Gunja, What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? Findings from the all confident in their or not at Commonwealth Fund Health Insurance in America Survey, March–June 2019 (Commonwealth Fund, Sept. 2019). * Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. ability to afford care if they Data: Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. were to become very sick. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 10 CONCLUSION After dropping significantly following the major coverage reforms in Medicaid has been a key component of the ACA’s coverage expansions, 2014, the U.S. uninsured rate has held steady or slightly increased, as and enrollment in Medicaid is now higher than initially projected our survey and others have shown. Four primary factors are at play: following the Supreme Court decision that made the expansion optional for states.14 Our survey indicates that nearly all those enrolled • Many states have not expanded Medicaid eligibility. in Medicaid are satisfied with their insurance, and it also suggests that • Premiums can be unaffordable for people with incomes just over expansion has support among the general public. A majority of adults the marketplace subsidy threshold ($48,560 for an individual or living in states that haven’t expanded Medicaid favor expansion, $100,400 for a family of four). including a majority of Republicans with incomes under 250 percent of poverty. • Congress and the Trump administration have passed laws and taken executive actions on the ACA, such as repealing the Since the ACA’s passage in 2010, Congress has not passed legislation individual mandate penalty and encouraging states to enact work to get more people covered or to improve the affordability or cost- requirements for Medicaid beneficiaries. protection of private plans. Though many states have stepped up in multiple ways, it’s clear that improving coverage for all U.S. residents • Lack of access to subsidized coverage among undocumented will require federal legislation. Several Democratic members of immigrants. Congress and presidential candidates have introduced bills or put This survey indicates that Congress’s repeal of the individual mandate forth proposals to that end.15 These approaches are an amalgam of penalty has had a small effect on people’s decisions to get health provisions that individually or collectively have the potential to make insurance this year, with about one in 10 uninsured adults opting not significant improvements in coverage. to get covered this year because of it. The Congressional Budget Office Our survey indicates that much of the public currently needs more is projecting that about 7 million people will lack coverage because of information before supporting a Medicare-for-all approach. Given the penalty repeal by 2021.12 the complexity of our health care system, this may also be the case Ongoing affordability concerns appear to play a more important regarding other approaches to improving coverage, including those role than the mandate penalty in people’s decisions to get coverage. advanced by Republicans. It may be up to the candidates to educate In our survey, about half of adults who visited the marketplaces but voters about what their proposals would mean for them and for the did not enroll in a plan said they couldn’t find affordable coverage. health care system, and what financing trade-offs might be required to Another recent survey found that affordability was the top reason achieve them. why uninsured adults didn’t seek coverage through the marketplaces in the first place, and a top reason why adults with a coverage gap had dropped their individual-market plan.13 commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 11 Table 1. Demographics of Overall Sample, Uninsured Adults, and Adults by Coverage Source Total adults Uninsured Employer Medicaid Individual Uninsured (ages 19–64) (rate) Percent distribution 100.0% 55.6% 12.8% 8.6% 13.8% 13.8% Age 19–34 34 32 38 30 45 18 35–49 32 34 31 31 30 13 50–64 33 32 30 37 24 10 Gender Male 49 51 39 43 52 15 Female 51 49 61 56 47 13 Race/Ethnicity White 60 66 51 64 45 10 Black 12 10 17 9 13 15 NOTES Hispanic or Latino 18 13 22 17 34 26 FPL = federal poverty level. 250% FPL is $30,350 for an Asian/Pacific Islander 5 5 5 5 3 10 individual and $62,750 for a Other/Mixed 4 4 4 4 4 13 family of four. Poverty status <250% FPL 46 24 91 44 73 22 ^ At least one of the 250%+ FPL 54 76 9 56 27 7 following chronic conditions: hypertension or high Health status No health problem 45 50 29 49 54 17 blood pressure; heart Fair/Poor health status, or any disease; diabetes; asthma, 55 50 71 51 46 11 chronic condition or disability^ emphysema, or lung disease; high cholesterol; or Political affiliation Republican 23 26 14 27 17 10 depression or anxiety. Democrat 29 30 31 33 21 10 ** The following states Independent 25 24 26 23 26 15 expanded their Medicaid program and began enrolling Something else 17 16 21 13 20 16 individuals in January 2019 State Medicaid Expanded Medicaid 65 67 76 60 46 10 or earlier: AK, AR, AZ, CA, CO, expansion decision** Did not expand Medicaid 35 33 23 40 53 21 CT, DE, HI, IA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MT, ND, State-based marketplace 29 31 34 30 18 9 Marketplace type*** NH, NJ, NM, NV, NY, OH, OR, Federally facilitated marketplace 71 69 66 70 81 16 PA, RI, VA, VT, WA, WV, and the Region Northeast 17 18 19 19 11 9 District of Columbia. All other states were considered to North Central 21 21 24 14 18 12 have not expanded. South 38 36 29 40 52 19 *** The following states have West 24 25 29 27 19 11 state-based marketplaces: CA, CO, CT, ID, MA, MD, Adult work status Full time 57 75 23 52 42 10 MN, NY, RI, VT, WA, and the Part time 13 9 20 19 19 19 District of Columbia. All other states were considered to Not working 30 16 57 28 39 18 have federally facilitated Education level High school or less 36 25 53 30 59 22 marketplaces. Some college/technical school 32 31 34 39 27 12 College graduate or higher 32 44 12 31 14 6 DATA Registered 85 91 72 87 74 10 Commonwealth Fund Health Voter registration Insurance in America Survey, status Not registered 14 8 28 13 25 21 Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 12 Table 2. Would you favor or oppose eliminating all private health insurance and making public insurance like Medicare the only health insurance option for everyone, or do you not know enough about this to say? Strongly Somewhat Strongly or Somewhat Strongly Somewhat or Don't know Base: Adults ages 19–64 favor favor somewhat favor oppose oppose strongly oppose enough to say Percent distribution 17% 9% 27% 8% 25% 32% 40% Age 19–34 18 10 27 12 19 31 41 35–49 20 10 29 6 24 30 39 50–64 15 9 24 5 29 35 40 Gender Male 17 10 28 6 32 38 33 Female 18 8 26 9 18 27 47 Race/Ethnicity White 16 9 25 8 32 40 34 Black 17 11 28 6 9 15 56 Hispanic or Latino 21 8 29 8 15 23 47 Asian/Pacific Islander 23 11 35 8 7 15 50 Other/Mixed 20 12 32 8 30 38 30 Poverty status <250% FPL 19 9 28 7 15 22 50 250%+ FPL 16 10 26 8 33 42 31 Health status No health problem 13 10 24 9 30 39 36 Fair/Poor health status, or any 21 8 29 6 21 27 43 chronic condition or disability^ Insurance status Uninsured 18 6 23 5 20 25 51 Employer 16 11 27 9 30 39 34 Medicare 17 12 28 1 15 15 54 Medicaid 20 8 28 7 14 20 51 Individual 25 7 33 7 25 32 35 Political affiliation Republican 6 6 12 8 53 60 27 Democrat 28 15 43 8 7 15 41 NOTES Independent 17 10 27 9 25 34 38 FPL = federal poverty level. 250% FPL is $30,350 for an Region Northeast 17 10 27 8 18 26 46 individual and $62,750 for a North Central 14 9 23 8 27 35 41 family of four. South 17 9 26 8 26 34 39 ^ At least one of the following chronic conditions: West 21 10 30 7 25 32 37 hypertension or high Adult work status Full time 16 9 25 9 31 39 35 blood pressure; heart Part time 21 13 34 7 14 21 45 disease; diabetes; asthma, emphysema, or lung Not working 19 8 27 5 19 24 48 disease; high cholesterol; or Education level High school or less 14 7 21 4 20 24 54 depression or anxiety. Some college/technical school 17 9 26 10 26 36 37 College graduate or higher 21 13 34 10 29 39 27 DATA Voter Registered 17 10 26 8 30 38 34 Commonwealth Fund Health registration status Insurance in America Survey, Not registered 11 9 19 7 13 19 61 Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 13 Table 3. Under the health reform law, many Americans have gotten covered by Medicaid. States can choose whether to expand Medicaid to cover more of their residents. Do you generally favor or oppose expanding Medicaid? Base: Adults ages 19–64 who live in states that Strongly Somewhat Strongly or Somewhat Strongly Somewhat or Don't know have not yet decided to expand Medicaid* favor favor somewhat favor oppose oppose strongly oppose enough to say Percent distribution 42% 26% 68% 8% 14% 23% 8% Age 19–34 42 33 75 8 8 17 8 35–49 42 23 65 7 16 23 10 50–64 42 22 64 10 20 29 6 Gender Male 38 23 61 9 19 28 10 Female 46 29 75 8 10 18 7 Race/Ethnicity White 33 26 60 10 20 30 10 Black 60 27 87 6 2 8 4 Hispanic or Latino 50 27 77 6 7 14 8 Asian/Pacific Islander 34 31 66 5 21 26 8 Other/Mixed 53 13 66 10 17 27 6 Poverty status <250% FPL 52 25 77 7 7 14 8 250%+ FPL 33 27 60 10 21 31 9 Health status No health problem 37 26 63 11 16 26 10 Fair/Poor health status, or any 46 26 72 7 14 20 7 chronic condition or disability^ NOTES Insurance status Uninsured 50 22 72 7 8 15 12 FPL = federal poverty level. Employer 34 31 64 10 18 27 8 250% FPL is $30,350 for an Medicare 61 12 74 4 14 18 8 individual and $62,750 for a family of four. Medicaid 59 26 85 5 4 9 5 ^ At least one of the Individual 42 20 62 7 22 29 8 following chronic conditions: Political affiliation Republican 17 25 42 13 35 48 9 hypertension or high Democrat 68 23 91 4 2 7 2 blood pressure; heart disease; diabetes; asthma, Independent 45 29 74 9 11 19 6 emphysema, or lung Region Northeast 32 68 100 0 0 0 0 disease; high cholesterol; or depression or anxiety. North Central 41 22 63 10 15 25 11 * The following states have South 43 26 69 8 14 22 8 not expanded their Medicaid West 24 34 58 16 22 38 4 programs: AL, FL, GA, ID, KS, Adult work status Full time 37 26 63 10 19 29 8 MS, MO, NC, NE, OK, SC, SD, TN, TX, UT, WI, and WY. Ballot Part time 43 32 75 8 5 13 9 initiatives to expand were Not working 50 24 74 6 10 17 8 approved in three states — ID, NE, and UT — but the Education level High school or less 45 26 71 8 11 19 10 states have not yet expanded. Some college/technical school 39 27 66 9 17 25 7 College graduate or higher 42 25 66 9 17 26 8 DATA Voter Registered 40 26 66 9 17 27 7 Commonwealth Fund Health registration status Not registered 37 33 70 9 6 15 13 Insurance in America Survey, Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 14 Table 4. Overall, how satifised are you with your health insurance? Very or Not too or Somewhat Not too Not at all Base: Insured adults ages 19–64 Very satisfied somewhat not at all satisfied satisfied satisfied satisfied satisfied All adults 48 37 85 8 6 14 <250% FPL 50 36 86 7 6 13 250%+ FPL 47 37 84 9 6 15 Adults with employer coverage 48 38 86 8 5 13 <250% FPL 45 40 85 8 5 14 250%+ FPL 49 38 87 8 5 13 Adults with Medicaid coverage* 55 34 90 5 4 9 Adults with individual coverage** 35 39 74 13 13 25 <250% FPL 42 43 84 8 6 14 250%+ FPL 30 35 65 16 18 34 NOTES FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. * In our survey, most Medicaid beneficiaries earn <250% FPL. ** Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. DATA Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 15 Table 5. How confident are you that if you become seriously ill you will be able to afford the care you need? Very or Not too or Somewhat Not too Not at all Base: Adults ages 19–64 Very confident somewhat not at all confident confident confident confident confident All adults 30 31 61 18 20 38 <250% FPL 24 29 53 19 27 46 250%+ FPL 35 33 68 16 15 31 Adults with employer coverage 35 36 70 17 12 29 <250% FPL 29 36 65 17 16 34 250%+ FPL 37 35 72 16 11 27 Adults with Medicaid coverage* 28 31 59 18 21 39 Adults with individual coverage** 24 33 58 20 21 41 <250% FPL 20 30 49 23 26 49 250%+ FPL 28 36 64 18 17 35 Uninsured adults 10 16 26 19 53 72 <250% FPL 9 15 24 23 51 74 250%+ FPL 12 18 30 9 59 68 NOTES FPL = federal poverty level. 250% FPL is $30,350 for an individual and $62,750 for a family of four. * In our survey, most Medicaid beneficiaries earn <250% FPL. ** Individual includes adults enrolled in coverage on and off the Affordable Care Act marketplaces. DATA Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 16 NOTES 1. Stephanie Armour, “American Voters Have a Simple Health-Care Message 6. In the “other” category, 5 percent of respondents were enrolled in Medicare, for 2020: Just Fix It!,” Wall Street Journal, updated June 2, 2019. and Monmouth 4 percent in the individual market, and 3 percent cited other coverage. University Polling Institute, “Iowa: Biden Holds Lead, Warren on the Chase,” Monmouth University, Aug. 8, 2019. 7. Sara R. Collins and Roosa Tikkanen, “The Many Varieties of Universal Coverage,” Commonwealth Fund, updated Apr. 24, 2019; Sherry A. Glied 2. Edward R. Berchick, Jessica C. Barnett, and Rachel D. Upton, Health Insurance and Jeanne M. Lambrew, “How Democratic Candidates for the Presidency in Coverage in the United States: 2018, Current Population Reports (U.S. Census 2020 Could Choose Among Public Plans,” Health Affairs 37, no. 12 (Dec. 2018): Bureau, Sept. 2019); Robin A. Cohen, Emily P. Terlizzi, and Michael E. Martinez, 2084–91; and Sara R. Collins, Status of U.S. Health Insurance Coverage and Health Insurance Coverage: Early Release of Estimates from the National Health the Potential of Recent Congressional Health Reform Bills to Expand Coverage Interview Survey, 2018 (National Center for Health Statistics, May 2019); Sara R. and Lower Consumer Costs, Invited Testimony, U.S. House of Representatives Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Committee on Rules, Hearing on “Medicare for All Act of 2019,” Apr. 30, 2019. Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019); and Sara 8. We asked the question two different ways. Half the sample was asked, R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing “Would you favor or oppose making public insurance like Medicare the only Burden for Middle-Income Families (Commonwealth Fund, Dec. 2018). health insurance option for everyone, or do you not know enough about 3. The break in trend between 2018 and 2019 in the survey is not a statistically this to say?” Twenty-eight percent of respondents who were asked this significant change. It may reflect, however, the change in sampling method and question reported they were somewhat or strongly in favor, and 45 percent mode of response introduced into the survey in 2019. of respondents reported they do not know enough to say. The other half of the sample was asked, “Would you favor or oppose eliminating all private 4. At the time of the survey, the District of Columbia, Massachusetts, and New health insurance and making public insurance like Medicare the only health Jersey had mandate penalties in effect. Vermont passed an individual mandate insurance option for everyone, or do you not know enough about this to say?” effective in 2020, though it has yet to establish a penalty or other enforcement Twenty-seven percent of respondents who were asked this question reported mechanism. California and Rhode Island have since passed individual mandate laws. See “What Is Your State Doing to Affect Access to Adequate they were somewhat or strongly in favor, and 40 percent reported they do not Health Insurance?,” (Commonwealth Fund, updated Sept. 6, 2019). know enough to say. There was little to no difference in responses overall, or by demographics, including age, race/ethnicity, and political affiliation. 5. This estimate is across all uninsured adults in our sample. There is no change when we remove uninsured adults who live in one of the four states that had 9. Voters approved ballots to expand eligibility for Medicaid in Idaho, passed individual mandate legislation. Nebraska, and Utah in November 2018, but the states have yet to expand. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 17 10. Rachel Garfield, Kendal Orgera, and Anthony Damico, The Coverage Gap: 14. After the Supreme Court decision that made Medicaid expansion a state Uninsured Poor Adults in States That Do Not Expand Medicaid (Henry J. Kaiser option, CBO estimated that as of March 2015, Medicaid enrollment would Family Foundation, June 2018 and May 2019). increase by 10 million people. As of April 2019, Medicaid enrollment had increased by 15 million relative to the baseline. See Medicaid and CHIP 11. Congressional Budget Office, Federal Subsidies for Health Insurance Payment and Access Commission, “Medicaid Enrollment Changes Following Coverage for People Under Age 65: 2019 to 2029 (CBO, May 2019). the ACA,” MACPAC, May 2019. CBO estimates that in 2019, 12 million people had been made newly eligible because of the expansion. 12. CBO, Federal Subsidies, 2019. 15. Collins and Tikkanen, “Many Varieties,” 2019; Glied and Lambrew, “How 13. Munira Z. Gunja and Sara R. Collins, Who Are the Remaining Uninsured, and Democratic Candidates,” 2018; and Collins, Status of U.S. Health, 2019. Why Do They Lack Coverage? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018 (Commonwealth Fund, Aug. 2019). commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 18 APPENDIX Uninsured Rate for U.S. Adults Compared to Other National Surveys Since 2013 Preimplementation Lowest Current uninsured rate (%) uninsured rate (%) uninsured rate (%) Survey [95% CI] [95% CI] [95% CI] NOTES 1. Commonwealth Fund Affordable Care Act Commonwealth Fund Affordable 12.7% 13.8% Tracking Surveys, July–Sept. 2013, Feb.–Apr. Care Act Tracking Survey and 19.9% 2016; and Commonwealth Fund Health Insurance [11.5%–14.0%] [12.6%–15.0%] in America Survey, Mar.–June 2019. Commonwealth Fund Health [18.5%–21.4%] Insurance in America Survey1 (Feb.–Apr. 2016) (Mar.–June 2019) 2. Commonwealth Fund Biennial Health Insurance Surveys, Apr.–Aug. 2012, July–Nov. 2016, and June–Nov. 2018. 12.0% 12.4% Commonwealth Fund Biennial 19.3% 3. Robin A. Cohen, Emily P. Terlizzi, and Michael [10.7%–13.52%] [11.2%–13.7%] E. Martinez, Health Insurance Coverage: Early Health Insurance Survey2 [17.5%–21.3%] Release of Estimates from the National Health (July–Nov. 2016) (June–Nov. 2018) Interview Survey, 2018 (National Center for Health Statistics, May 2019). 12.4% 13.3% 4. Edward R. Berchick, Jessica C. Barnett, and National Health Interview Survey 20.4% Rachel D. Upton, Health Insurance Coverage in [11.7%–13.1%] [12.5%–14.1%] the United States: 2018 (U.S. Census Bureau, (NHIS)3 [19.7%–21.1.%] (2016) (2018) Sept. 2019). In 2019, the U.S. Census updated its processing system to include four changes: 1) a refinement of the population that the health Current Population Survey (CPS)4 — — 11.7% insurance estimates describe to exclude infants who were born after the end of the calendar- year reference period; 2) an improvement to 13.1% 16.3% the imputation process for households with Gallup Healthways Well-Being Index 5,6 20.8% incomplete and missing data; 3) the ability to (Q4 2016) (Q4 2018) construct and release new measures, including about marketplace coverage; and 4) the use Urban Institute Health Reform 9.8% 10.8% of subannual measures to capture when in the 17.4% calendar year a person had health insurance Monitoring Survey7 (Q1 2016) (Q1 2018) coverage. These changes mean that files based on these processing updates reflect different types of coverage in their definitions of public, private, and military health insurance coverage. As such, they are not directly comparable to previously released files. 5. Stephanie Marken, “U.S. Uninsured Rate at 11.4% in Second Quarter,” Gallup, July 10, 2015. 6. Dan Witters, “U.S. Uninsured Rate Rises to Four- Year High,” Gallup, Jan. 23, 2019. 7. Jennifer Haley et al., “Adults’ Uninsurance Rates Increased by 2018, Especially in States That Did Not Expand Medicaid — Leaving Gaps in Coverage, Access, and Affordability,” Health Affairs Blog, Sept. 26, 2018. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 19 Methodological Differences Between Surveys Survey Population Time frame Sample frame Response rate Commonwealth Fund Affordable Care Act Tracking Survey and U.S. adults ages July–Sept. 2013 to Dual-frame, RDD 2013: 20.1% Commonwealth Fund Health 19–64 Mar.–June 2019 telephone survey 2019: 7.6% Insurance in America Survey1 2012: 22% for Commonwealth Fund Biennial U.S. adults ages Apr.–Aug. 2012 to RDD telephone survey landline, 19% for cell Health Insurance Survey2 19–64 June–Nov. 2018 2018: 5.1% National Health Interview Survey U.S. adults ages Multistage area 2013 to 2018 70% (NHIS)3 18–64 probability design Probability-selected U.S. adults ages Current Population Survey (CPS) 2018 sample; personal and 2018: 85%5 19–64 telephone interviews4 Before 2018: dual-frame RDD telephone survey U.S. adults ages 2013 to Oct.–Dec. NOTES Gallup Healthways Well-Being Index6 2018: address-based 18–64 2018 sampling frame with 1. Commonwealth Fund Affordable Care Act web survey Tracking Surveys, July–Sept. 2013, Feb.–Apr. 2016; and Commonwealth Fund Health Insurance in America Survey, Mar.–June 2019. KnowledgePanel- 2. Commonwealth Fund Biennial Health Insurance Urban Institute Health Reform U.S. adults ages July–Sept. 2013 to probability-based Surveys, Apr.–Aug. 2012, July–Nov. 2016, and ~5% Monitoring Survey7 18–64 Jan.–Mar. 2018 internet panel of 55,000 June–Nov. 2018. households 3. National Center for Health Statistics, “About the National Health Interview Survey,” Centers for Disease Control and Prevention, updated Jan. 16, 2019. 4. Current Population Survey (CPS), “Methodology,” U.S. Census Bureau, n.d. 5. Current Population Survey (CPS), “Non-Response Rates,” U.S. Census Bureau, updated Aug. 13, 2015. 6. Gallup, “How Does the Gallup National Health and Well-Being Index Work?,” n.d. 7. Urban Institute, “HRMS Frequently Asked Questions,” n.d. commonwealthfund.org Survey Brief, September 2019 What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? 20 ABOUT THE AUTHORS ACKNOWLEDGMENTS Sara R. Collins, Ph.D., is vice president for Health Care Coverage and The authors thank Robyn Rapoport, Sarah Glancey, Erin Czyzewicz, and Access at the Commonwealth Fund. An economist, Dr. Collins joined Christian Kline of SSRS, and David Blumenthal, Elizabeth Fowler, Eric the Fund in 2002 and has led the Fund’s national program on health Schneider, Chris Hollander, Bethanne Fox, Deborah Lorber, Paul Frame, insurance since 2005. She also directs the Fund’s research initiative Jen Wilson, Gabriella Aboulafia, Corinne Lewis, and Jesse Baumgartner on Tracking Health System Performance. Since joining the Fund, she of the Commonwealth Fund. has led several national surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance For more information about this brief, please contact: coverage and policy. She has provided invited testimony before several Sara R. Collins, Ph.D. Congressional committees and subcommittees. Prior to joining the Vice President, Health Care Coverage and Access Fund, Dr. Collins was associate director/senior research associate at The Commonwealth Fund the New York Academy of Medicine. Earlier in her career, she was an srccmwf.org associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Office of the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. Munira Z. Gunja, M.P.H., is senior researcher in the Health Care Coverage and Access program at the Commonwealth Fund. Ms. Gunja joined the Fund from the U.S. Department of Health and Human Services in the office of the Assistant Secretary for Planning and Evaluation (ASPE), Division of Health Care Access and Coverage, where she received the Secretary’s Award for Distinguished Service. Before joining ASPE, Ms. Gunja worked for the National Cancer Institute where she conducted data analysis for numerous studies featured in scientific journals. She graduated from Tulane University with a B.S. in public health and international development and an M.P.H. in epidemiology. Editorial support was provided by Deborah Lorber. commonwealthfund.org Survey Brief, September 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.